ELECTRICAL SAFETY INSPECTION FORM
International version
Overall assessment:
□
Scheduled inspection Test item: 1, 2, 3, 9
□
Unopened repair type Test item: 1, 2, 3, 9
□
Opened repair type, not modify the power part
including transformer or patient circuit board
Test item: 1, 2, 3, 4, 5, 9
□
Opened repair type, modify the power part
including transformer or patient circuit board
Test item: 1, 2, 3, 4, 5, 6, 7, 8, 9
Location Technician
Equipment Control Number
Manufacturer Model SN
Measurement equipment /SN Date of Calibration
INSPECTION AND TESTING
Pass/Fail Comments
1 Power Cord Plug
2 Device Enclosure and Accessories
3 Device Labeling
4 Protective Earth Resistance Ω Limit 0.2 Ω
5 EARTH Leakage
— —
Limit
NC:500μA
SFC:1000μA
Normal condition(NC) μA
Single Fault condition(SFC) μA
6* Patient Leakage Current
— —
Limit
CF AP
NC:10μA, SFC: 50μA
BF AP
NC:100μA,SFC: 500μA
Normal condition(NC)
μA
Single Fault condition(SFC) μA
7* Mains on Applied Part Leakage Limit
CF AP: 50μA
BF AP: 5000μA
8* Patient Auxiliary Current
— —
Limit
CF AP
NC:10μA,SFC: 50μA
BF AP
NC:100μA,SFC: 500μA
Normal condition(NC)
Single Fault condition(SFC)
9 Functional test (parameters tested):
Note: The test items marked “*” are needed only for incoming inspections and after repairs or
modifications that may have affected lead leakage [NFPA 99 (2005)8.5.2.1.3].
Deficiency / Note:
Name: _____________________________ Date / Signature: _________________________________
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